Category: Main Page

My Mother Tongue, Krobo/Dangme-Gã of south-east Ghana was first written by the Swiss-German Basel Missionaries who not only translated the Bible for us, but also wrote hymns for us with the help of local experts born in the Gold Coast. They did a remarkable job, but as the Ghanaian vowel imparts no less than 6 meanings to any consonant my parents and grandparents had to look at the context in which a written word appeared before pronouncing the word correctly. For example, the word written ‘ta’ can mean chew, war, giant ant, to fish out of a bowl, palm tree, or narrate in Krobo/Dangme. My parents were adept at quickly scanning a sentence mentally before deciding what the ‘ta’ they had just read stood for.
To read more click here to view the PDF document.

Origin of the Genetic Code is suprascientifichttp://jrsm.rsmjournals.com.newproxy.rsm.ac.uk/cgi/eletters/103/2/43 Journal of Royal Society of Medicine March 15 2010
Response: The disappointments of the double helix: a master theory
Origin of the genetic code is suprascientific
The title of Dr James Le Fanu’s magnificent article suggests inadvertently that, with all the advances in genomic research, our inability to have “a mind capable of understanding the origins of the universe” [1] is to be blamed on the double helix when he could justifiably have pointed his finger at ourselves.
Discoverer of the ‘Double Helix’, Nobel Laureate Francis Crick, confessed his inability to explain “the origin of the genetic code” [2]. I discovered the reason why from Professor Sir Peter Medawar FRS OM, another Nobel Laureate, who taught that questions like origins not only go “beyond the explanatory confidence of science” [3 (p. xiii)] but also that “science cannot answer these ultimate questions and no conceivable advance of science could empower it to do so” [3 (p. 59)].
It is beginning to dawn on some of the world’s brightest scientists that Medawar is quite right, and that DNA, with its genetic code, belongs to the lowest rung (statistics) of information-transmission whose other rungs, in ascending order, capable of sending a message and producing results are syntax, semantics, pragmatics, and apobetics [4]. Useful messages do not arise anyhow. The first question I ask when I receive useful information is not “How was this information sent?” but “Who sent this?”
Until we begin to accept Medawar’s humbling limitation of the “explanatory confidence of science” [3] and admit that the origin of the universe and of DNA information programming in particular, is in the realm of the “suprascientific” [5] we shall continue (as we do at present) to be “whistling in the dark to keep our scientific courage up” [5].
Felix ID Konotey-Ahulu, Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast, Ghana and Consultant
Physician Genetic Counsellor, Sickle & Other Haemoglobinopathies 10 Harley St., London W1G 9PF
E-mail: felix@konotey-ahulu.com
Competing interests: None declared
References
1 Le Fanu J. The disappointments of the double helix: a master theory. J R Soc Med 2010; 103: 43-45. DOI.101258/jrsm.2009.09k077 February 2010
2 Crick FHC. The origin of the genetic code. J Mol. Biology 1968: 38: 367-379.
3 Medawar P. The Limits of Science. Oxford. Oxford University Press, 1985 pp xiii & 59.
4 Gitt Werner. In the beginning was Information. Christliche Literatur-Verbretung e.V.
Postfach 110135.33661 Bielefeld, Germany, 2001.
5 Konotey-Ahulu FID. The suprascientific in clinical medicine – a challenge for
Professor Know-All http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121901
Brit Med J. 2001; 323: 1452-1453

I am very concerned at what appears to be inadequate cooperation among medical practitioners who I had always assumed worked in harmony to improve the quality of patients' lives and save lives that can be saved.

If I have understood correctly, in the first few years of training, medical practitioners learn that opiates, notably morphine and heroin (Diamorphine) have an effect on the cerebellum and deprive the system of oxygen. It is therefore advised that as there are numerous alternatives available, they should absolutely not be used as a pain killer unless a patient is terminally ill, very near to death and in excruciating pain which no other pain killer can relieve.

Do I understood that those physicians who continue to prescribe these drugs have forgotten what they have been taught or choose to ignore the fact even when reminded? What is happening to the life-saving dictum of the profession where some doctors are concerned?

In November 2008, I went to an emergency room at a clinic in Geneva , Switzerland where I live, with a blasting chest pain. My condition was soon further complicated by excruciating pain in my left hip.

My new lease on life is because medical practitioners did not contest my refusal of a morphine injection to relieve excruciating pain in my chest and hip. The physicians attending to me would have loved to relieve me of the pain with morphine but respected the knowledge, however little, and understanding I had of the way in which opiates affect the brain and therefore the entire system. They deprive the system of oxygen which is desperately vital in my condition, Sickle Cell Disease.

I had double pneumonia and pleurisy. The infection had provoked a sickle cell crisis. Before they had realised the extent of my illness, the fact that I was a sickle cell disease (SC) patient was enough for the physicians attending me NOT to insist on administering morphine. One of them said that my pain had reached the maximum the human body could endure.

Unfortunately, some physicians force patients to have morphine. Whether one is a sickle cell patient or not, opiates in my opinion, are not to be recommended.

I am allergic to aspirin and therefore must avoid no fewer than 34 prescription and over-the-counter medications, including Ketorolac (Toradol) which is very effective in relieving excruciating pain.

There are so many misconceptions about sickle cell disease that I took the book “The Sickle Cell Disease Patient” by F I D Konotey-Ahulu to the clinic and my daughter handed it to the physician attending to me. My three adult children are well informed about my health issues and therefore telephoned Professor Felix Konotey-Ahulu abroad for guidance. My physicians were very happy to consult with him by telephone. He confirmed that I was right to refuse the administration of morphine and together they co-operated in making me comfortable and well again.

I was fortunate enough not to need a blood transfusion (neither total nor partial).

It may help medical practitioners to know that over the 12-days that I was in the clinic in Geneva, medication I was given was Dafalgan, Valium, Tramal, Perfalgan, Rocephine, Klacid, Franxiperine, Nexium and Tavanic and Motilium lingual. I also had Oxygen, NaCl and Glucose. No Morphine or Diamorphine!

On leaving the clinic in Geneva , I went to a convalescence clinic. A physician at the convalescence clinic asked why I had refused morphine. When I explained why, a colleague of his pointed to the back of his head, reminding him of the effect opiates have on the brain.

I am privileged to interact with physicians for whom I have the highest respect, one reason being because they take due consideration of what I, their patient, say and they listen to my children as well. The physicians are humble enough to take hold of a receiver and cooperate with another physician abroad in saving a life. They admit to me that they have been very happy to deepen their knowledge and would be pleased to learn more.

Had I been given the morphine or any other opiate, because of my double pneumonia with sickle cell disease, I would not be writing today, pleading with physicians to have compassion on patients who sometimes suffer very uncomfortable psychological problems (however temporary) as a result of having been given opiates and those who die as a result of having been given opiates.

The physicians who seem not to understand should try putting themselves in the position of families plunged into unbearable grief because of carelessness – a loved one was given opiates unnecessarily.

In spite of myself I begin to wonder whether Professor Felix Konotey- Ahulu's very practical and uncomplicated life-saving advice is being ignored by some medical practitioners because of his African origins. I believe his advice is based on what every medical practitioner learns at medical school.

Susan Mayor, 5 September, has done well to draw attention to 2 reports that reveal “the numbers of people dying because of poisoning from legal and illegal drugs are still increasing” [1] The first report said “Almost a third of the deaths where specific drugs were mentioned on the death certificate were related to heroin or morphine” [1, 2] The second report from St George’s University of London showed a 2.7% rise in the number of drug related deaths confirmed by inquest. Here too “Heroin and morphine accounted for most of these deaths” [3]. And these were the very drugs that the NCEPOD Report [4] found had produced deaths in sickle cell disease patients from overdose, and about which I continued to protest [5- 8].

HOW LONG WILL THIS CONTINUE FOR?

How long this situation is destined to continue is not clear. Writing to the Prime Minister and Health Ministers as I did, produced a response from Downing Street [6], but other ministers did not even bother to acknowledge my letters of concern. The United States of America has banned Diamorphine (Heroin) from all clinical practice [9], and that great country does not even have a National Institute of Health and Clinical Excellence (NICE). I would dearly want to know what percentage of the members of NICE are practicing Clinicians. Do they not know that Diamorphine suppresses respiration thus producing more in vivo sickling in sickle cell crisis [10, 11, 12]? Never mind how many UK Professors of Haematology approve of the practice, but do the Clinicians on NICE not know that it is this “legal” Diamorphine that (as Susan Mayor writes) is pushing up “the numbers of people dying because of poisoning from legal and illegal drugs” [1]?

IS MY PROTEST JUSTIFIED OR NOT?

But why do I continue protesting like this? ANSWER: First of all, I did not train in the bush somewhere in Africa. I was trained in LondonUniversity’s Westminster Hospital School of Medicine by Physicians and Surgeons of King George VI and Queen Elisabeth II. My teachers taught me never to give Diamorphine or morphine to someone who could not breathe and whose red cells were bound to sickle further and clog up vital organs [13]. Secondly, I was second born of my parents’ 11 children 3 of whom had sickle cell disease, allowing me to know much about the disease before I went to university [14]. Thirdly, I was once in charge of the largest sickle cell disease clinic in the world, seeing personally hundreds of patients in sickle cell crisis [15, 16], salvaging many to grow up to use their brilliant non-sickling genes to achieve great things later in life, an experience which led me to begin writing about the sickle cell disease patient more than 44 years ago [17].

MY ADVICE TO NATIONAL INSTITUTE OF HEALTH AND CLINICAL EXCELLENCE

In the light of the above I make no apologies to take it upon myself to advise NICE to stop standing on the sidelines, and add to their many pronouncements one that forbids the “legal” use of Heroin (Diamorphine) for sickle cell disease patients. This, at least, was one thing NICE could learn from the USA [9].

GENETIC COUNSELLING AND VOLUNTARY FAMILY SIZE LIMITATION

The real answer for now, and the future, as I have been saying for decades is Genetic Counselling and Family Planning [18, 19] warning my fellow Africans that if they did not check themselves for a beta-globin gene variant (an ACHE gene) they might suddenly find themselves with a child born with an ACHEACHE phenotype (ACHE from father and ACHE from mother), like Sickle Cell Disease, and “the genetic burden on the National Health Service will go up and up” [20]. If born in the UK, the child could never escape Diamorphine treatment in sickle cell crisis. Was that really a prospect my country men and women would cherish?

SIR,-Dr John Black's article (30 March, p 984) is most helpful. Many family doctors are quite familiar with much of what he has so lucidly stated. The reason why many children (and adults) with sickle cell disease continue to die “before their time” in the UK and elsewhere is failure to appreciate certain facts relating to presentation, a failure of anticipation, and what I usually call a combination of circumstances.

First, presentation. Epistaxis, priapism, enuresis, numbness of the lower lip, sudden aphasia, hemiplegia, blood in the urine, deep jaundice, large tummy, nails white as a sheet, loud precordial murmurs, bruit de diable at the root of the neck, unexplained fever, cough with tachypnoea, fatigability, swollen hands may each and severally be the first indication that the child has sickle cell disease.' Alternatively, a child's condition may have nothing to do with sickle cell disease but may later be worsened by it-for example, within seven days lobar pneumonia can become pneumonia plus infarction plus pulmonary abscess.' Presentations may also differ from those described in the textbooks. (1) Teenagers of 12, 13, 14, or 15 years with SS disease may have spleens which, far from vanishing, are enlarged. (2) The child with genuine SS disease (parents AS, AS) with haemoglobin of 12-3 g/dl should not be treated as having sickle cell trait, because the potential for devastating in vivo sickling is there. (3) Extreme fatigability with “nails as white as a sheet” during an attack of measles indicates an aplastic crisis from the measles virus. Haemoglobin drops to 2-5 g/dl within 48 hours. As little as 100-150 ml of packed cells for a 5 year old child and not more than one unit for a 15 year old given over eight hours is lifesaving, even when the haemoglobin was less than 3 g/dl to start with.

Secondly, clinicians should anticipate disasters in patients with sickle cell disease. For example, if perioperative fluid therapy is not planned for a child about to undergo surgery the child will end up with a stroke. Anaesthetists are now more careful than ever so their success is virtually 100″,,, but fluid management before, during, and after operation often leaves a lot to be desired. The clinician should also be aware that the patient who has been admitted and discharged twice within the past week has come in again to die unless the whole management is overhauled.

Thirdly, there are many dangerous combinations of circumstances that may lead to disaster for the unwary. (1) Personnel: the houseman or GP is away for the weekend; the locum has little clue about what is happening and goes by the packed cell volume or haemoglobin concentration rather than the patient's condition; the casualty department may refuse to admit the patient, quibbling over whether the patient should go under a physician or a haematologist. (2) Clinical: abdominal pain might be due to sickle cell crisis,2 3 or the crisis could also have been precipitated by acute appendicitis.' (3) Genetic: hardly any west African with sickle cell anaemia is without one or more of the other hereditary erythrocytopathies: 86'U/ have concomitant lac or 2ac thalassaemia, and, although this is supposed to ameliorate the SS phenotype, 2OO, of the men and 16″(, of the women also have glucose-6- phosphate dehydrogenase (G6PD) deficiency.4 Contrary to what is claimed from the USA, G6PD deficiency on top of sickle cell disease is an added liability4 (Luzzato L, paper at International Symposium on Sickle Cell Anaemia, Abidjan, Ivory Coast, 1975). Workers in the UK should always identify which of their patients have G6PD deficiency, because several antimicrobial agents and analgesics which are given to help may in fact harm the patient.

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD)published a report in May 2008 which showed that within the 2 years January1 2005 to December 31 2006 “Nine out of the 19 patients with sickle celldisease who had pain on admission and who then died had been givenexcessiove doses of opiods”.

Later, on 9 July 2008 in the House of Commons, another report was publishedcalled “The Standards for The Clinical Care of Adults with Sickle CellDisease in the UK”. The Chairman of the Group that produced the reportdescribed the present care of patients in the UK as a “hit and miss affairdepending on the attitudes and experience of health professionals”. DrKonotey-Ahulu's reaction to this in the British Medical Journal on line isreproduced in full below http://www.bmj.com/gi/eletters/337/jul11_2/a771

If I remmeber rightly, the little bottle of Aerobic Oxygen will last up to two months if you take about 20 drops three times daily.

I am grateful for your question because I forgot a very important point about pain killers.

My brother “ended up” having a sickle cell crisis in late spring last year (2007). Too much traveling by air, long working hours and enjoying wine or some other alcohol as an aperitif or with his evening meal were among things that led to the crisis.

He was given morphine to alleviate the excruciating pain. As Professor Konotey-Ahulu put it when they spoke over the phone while my brother was in a hospital in Maine, “morphine will keep you in hospital”. (The School of Medicine in Ghana teaches doctors that morphine should be used only when a terminally ill patient is in great pain.). Fortunately, the medical staff in Maine was willing to learn. As soon as they were told that morphine was supressing the oxygen supply to his body (the crisis meant he already was suffering from lack of oygen), on Prof's advice, he was given shots of “Ketorolac”. Within 48 hours my brother had been discharged from hospital.

Some doctors in hospitals in Europe are very stubborn and patietns and their families have to be very, very firm in refusing the use of morphine to alleviate pain. Last summer, a father flew in from Canada and shared his daugher's hospital room for a week, until she was discharged, so that treatment that was further aggravating her condition would be stopped. She had been given morphine and a full blood transfusion instead of a partial blood transfsion, so her blood became even thicker and normal oxygen supply to her body and brain was furher obstructed.

Please do read the Professor's blog and website regularly and, please do contact me, if necessary, for patient-to-patient exchanges.

There is nothing like walking into a doctor's office with tags on the essential pages of his book on The Sickle Cell Patient.

Rule 001 = live healthily, for living a healthy life is living without sickle cell crises. Dr. Konotey-Ahulu asked about your job – that also falls into the “living healthily” category because if it is tiring and stressful you will need to do something about that.

A few more rules:

1. Never allow morphine or any other opiate to be administered as a pain killer when in crisis.

2. Inform yourself about partial blood transfusion.

3. Know what your hemoglobin level is and never accept a blood transfusion that will raise it far above what your body is used to living relatively comfortably with.

4. Avoid alcohol – make water your favorite drink.

I hope you have had your spleen checked. Please do so as soon as possible.

My apologies for not writing sooner. I have not checked my e-mails in several days. Below are a few points which come to mind immediately. I shall be 60 in June.

As long as you feel unwell and have pain in your spleen or any other part of your body, I would avoid flying until your health problems are dealt with. There is nothing like preventing a sickle cell crisis as a crisis is a miserable and unbelievably painful experience.

Drink two to three liters of water each day, avoid alcohol, do not eat heavy meals (prefeably four or five lighter meals a day), and do not have your last meal too late at night, keep your body weight down, stay well rested, never exhaust yourself, do gentle exercise, walk. Always dress warmly; even in hot weather, carry a light shawl around with you to protect you from sudden exposrue to cool draughts and air conditioning.

Your eyes need to be checked regualrly (i.e. approximately every six months) to make sure that you do not have any bleeding into the retina. Unfortunately, this is a problem we 'SC' patients suffer from. If blood vessels in your eyes rupture during a trip, you will most porbably not be able to fly home for medical care so it is extremely important that you should be in good health before flying.

I have found it extremely helpful to own a copy of “The Sickle Cell Disease Patient” by Dr Konotey-Ahulu, and I encourage doctors to have a copy on their bookshelves. I also refer them to his website www.konotey-ahulu.com We need to know our bodies and about our ailment so we can educate doctors as only too few know about it.

I have learned from Dr. Konotey-Ahulu that there is a big difference between managing a patient and treating a disease.

You can help any open-minded, receptive general practitioner who does not know much about sickele cell disease to manage you correctly.

Please ask Dr. Konotey-Ahulu what blood tests you should have. My spleen has disappeared – if I remmeber rightly, it was overworked fighting infections. Every three years or so I have a “pneumovax” shot and, at the beginning of winter, take a course of medication to make my immune system react quickly whenever I have an upper respiratory tract infection.

A few drops of Aerobic Oxygen (stabilised oxygen) in a glass of water about three times a day is very helpful. It is not sold in the US but can be ordred from Canada. As I do not have the address within reach at the moment, I shall send it to you tomorrow.

All that I have learned about managing my problems with sickle cell disease has been thanks to Dr. Konotey-Ahulu. My using Aerobic Oxygen is also thanks to him.

China and Australia will be well within your reach if you are in good health.

Please spend a couple of years looking after your health then plan your trips with the necessary days of rest well below an altitude of 2000m. The correct and constant air pressure on board an aircraft is also important, particularly on long-haul flights.

I live in Geneva, Switzerland. A small group of us is reaching out to other sicke cell patients in Geneva and forming a suport group as there are misconceptions and errors in treatment that are repeated. We patinets need to know our bodies and be firm with doctors. In the long run, they respect us for our knowledge and many of them are grateful to us for helping them improve our health.

If you know of any other sicke cell patints in Fort Lauderdale, you may wish to form a support group.

With best wishes,

Mawunu

felix Konotey-Ahulu <admin@sicklecell.md> wrote:

Dear Judith

Thanks for writing. I'm off somewhere at the moment so I cannot respond in detail to your letter.

Where are you? What do you do?

I'm copying your letter to a super lady who can help you. Her name is Mawunu Chapman Nyaho.

On the Home Page you will find on the right hand side 'PUBLICATIONS'. Click on it. That brings you to a page with dates from 1965. Scroll down the years to the Year 2001. Read all 4 articles listed in that year before getting back to me.